Pacific Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pacific, Missouri.
- Location
- 105 South Sixth Street, Pacific, Missouri 63069
- CMS Provider Number
- 265337
- Inspections on file
- 13
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pacific Care Center during CMS and state inspections, most recent first.
Staff failed to maintain a comfortable sound level when a broken keypad on a secure exit door caused a loud beeping noise every time the door was used over an extended period. The door, which led to the laundry area and was used frequently by CNAs, laundry, housekeeping, and maintenance staff, emitted a loud alarm-like sound for at least 15 seconds with each use. A resident reported being awakened early in the morning and feeling distressed by the constant beeping, while another resident said the noise sounded like a fire alarm and occurred throughout the day and sometimes at night, bothering everyone. Staff acknowledged the keypad had been broken for weeks, but facility leadership, including the DON and administrator, were unaware of the issue until surveyors arrived, and the maintenance director reported delaying repair pending payment of invoices.
The facility failed to notify the State LTC Ombudsman of resident transfers to the hospital for four residents. The facility lacked a policy for such notifications, and staff interviews revealed confusion and lack of communication regarding the notification process. The SSD relied on bed hold information from nursing staff, which was not consistently provided, leading to incomplete notifications.
The facility failed to notify residents and their representatives in writing about the bed hold policy during transfers to hospitals or therapeutic leave. This issue affected four residents, with no documentation found in their medical records. Interviews with staff revealed confusion and lack of accountability regarding the completion and monitoring of bed hold forms, contributing to the deficiency.
The facility failed to develop and implement comprehensive care plans for several residents, leading to discrepancies between care plans and physician orders. Issues included inaccurate documentation of hospice services, missing directions for medications and dietary needs, conflicting code status information, and unaddressed use of bed rails and smoking habits. Staff interviews revealed that care plans were not updated as required, contributing to these deficiencies.
The facility failed to provide scheduled showers for eight residents due to an inaccurate master shower schedule. Residents, including those with cognitive impairments and hospice care, were not consistently listed, leading to missed showers. Staff interviews revealed confusion over responsibility for updating the schedule, resulting in inadequate care.
The facility failed to conduct necessary bed rail assessments and obtain informed consent for three residents, despite having a policy requiring these actions. Observations showed consistent use of bed rails without updated assessments or consents. Interviews revealed confusion among staff about responsibilities for bed rail assessments and consent, contributing to the deficiency.
The facility failed to ensure that four nurse aides completed the required training within four months of employment. Personnel files lacked documentation of completed training, and one aide did not perform proper hand hygiene during care. Interviews revealed a lack of clarity and communication regarding responsibility for monitoring training completion, resulting in non-compliance and continued work without completed training.
The facility failed to follow its policy for narcotic reconciliation at shift changes, as narcotic count sheets from April to July 2024 lacked the required two staff signatures. Observations and staff interviews confirmed that narcotic counts were often not performed by two licensed staff members, as required. Facility leadership was unaware of these lapses, which represent a significant deficiency in pharmaceutical services.
Facility staff failed to perform proper hand hygiene during incontinence care for three residents, leading to a deficiency in infection prevention. Staff were observed changing gloves without washing hands, and the facility's handwashing policy lacked guidance on alcohol-based sanitizers. Interviews revealed inconsistencies in the availability of hand sanitizers, complicating adherence to hygiene protocols.
The facility failed to conduct regular inspections of bed rails, leading to potential safety risks for four residents. Despite policy requirements, entrapment assessments were not completed, and observations showed residents with bed rails up without proper documentation. Staff interviews revealed confusion about responsibility for entrapment measurements, posing a risk of harm.
The facility failed to properly contain waste, as the outdoor dumpster was uncovered and lacked lids, with waste scattered around it. This led to two cats rummaging through the waste. The administrator and Dietary Manager were unaware of the lack of a lid and there was no written policy for waste disposal.
A housekeeper in an LTC facility misappropriated funds by stealing a resident's wallet and using the debit card without consent. The resident, who was cognitively intact, reported the missing wallet and unauthorized charges. An investigation confirmed the housekeeper's actions through surveillance footage and interviews, revealing a failure in protecting the resident's belongings.
The facility failed to maintain an operational call light system as staff did not consistently use wireless nurse call pagers, affecting 56 residents. Call lights were often unanswered for extended periods, with staff relying on central computer stations and ticker screens instead of pagers. The DON and administrator acknowledged the issue, emphasizing the need for prompt response to call lights.
The facility failed to update care plans for four residents after falls, despite policy requirements for ongoing assessment and updates. The DON acknowledged responsibility, but care plans lacked new interventions. Communication issues, such as CNAs not having access to event reports and reliance on verbal updates, contributed to the deficiency.
A resident with cognitive impairment and hemiplegia did not receive timely toileting assistance and incontinence care, resulting in the resident remaining wet and unclean. The care plan lacked specific instructions on toileting frequency, and a CNA failed to perform necessary perineal care. Interviews with staff highlighted the importance of regular toileting to prevent skin breakdown and infection.
A CNA failed to secure the safety strap during a mechanical lift transfer for a cognitively impaired resident with hemiplegia, leading to a deficiency in accident prevention. The resident's right arm was not holding onto the lift, and the shin strap was missing. The DON and administrator were unaware of the missing shin strap, despite recent staff training on transfers.
Failure to Maintain Comfortable Sound Levels Due to Broken Exit Door Keypad
Penalty
Summary
Facility staff failed to maintain a comfortable and homelike environment by not ensuring a functional keypad on the secure metal door leading to an outside exit on C hall, resulting in a loud, continuous beeping noise each time staff entered or exited. The facility lacked an environmental policy, and the keypad had been broken for at least a couple of weeks, according to staff. The beeping occurred whenever staff held down the metal bar for 15 seconds to open the door and continued until a code was entered on the other side. Multiple observations over several days showed frequent, loud beeping from this door as various staff, including maintenance, CNAs, laundry, and housekeeping personnel, repeatedly used the door throughout the day. Each observed use required holding the bar down for 15 seconds, triggering the loud alarm-like sound. This occurred many times in a short period on multiple days, demonstrating an ongoing and unresolved environmental issue affecting the sound level in the hallway. Residents reported that the noise disturbed their rest and comfort. One resident stated the beeping came from the broken back door to the laundry room, reported that staff began arriving early in the morning, and said the noise often woke them up and made them feel "crazy." Another resident said the loud beeping sounded like a fire alarm, believed the door was broken, and reported being awakened in the mornings and hearing the sound periodically all day and sometimes at night, stating it bothered everyone. Staff interviews confirmed awareness of the broken keypad and frequent use of the door, while leadership interviews showed that the DON and administrator were not aware of the problem until the surveyors arrived, and that the maintenance director was waiting on invoices to be paid before ordering the needed part.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility staff failed to notify the State Long-Term Care Ombudsman in writing of resident transfers to the hospital, including the reason for transfer, for four residents out of 14 sampled. The facility's policies did not include a procedure for notifying the ombudsman about transfers and discharges. The medical records of the residents involved did not contain documentation that the ombudsman was notified of their transfers to acute care or the emergency room. This lack of notification was identified for residents who were transferred on various dates and subsequently readmitted to the facility. Interviews with facility staff revealed a breakdown in the notification process. The Social Service Director (SSD) indicated that notifications to the ombudsman were dependent on receiving bed hold information from nursing staff, which was not consistently completed. The Administrator acknowledged the issue, stating that ombudsman notifications were not being completed as required. Other staff members, including an LPN, the ADON, and a Nurse Consultant, were either unaware of the notification responsibilities or the fact that notifications were not being completed. This indicates a lack of clarity and communication among staff regarding the notification process for resident transfers.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform residents and/or their representatives in writing about the bed hold policy at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for four residents out of a sample of 14, with the facility's census being 54. The facility's Bed Hold Policy Guidelines require notification upon admission, at the time of transfer, and during non-covered therapeutic leave. However, reviews of the medical records for the affected residents showed no documentation of such notifications being provided prior to their transfers. Interviews with facility staff, including the Social Service Director, the administrator, LPNs, the ADON, and the Nurse Consultant, revealed a lack of clarity and accountability regarding the completion and monitoring of bed hold forms. The charge nurses were identified as responsible for completing these forms, but there was a breakdown in the process, as evidenced by the absence of completed forms. The administrator acknowledged awareness of the issue, while the ADON and Nurse Consultant were unaware that the bed holds were not being completed. This lack of communication and oversight contributed to the deficiency in notifying residents and their representatives about the bed hold policy.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility staff failed to develop and implement comprehensive person-centered care plans for seven residents out of a sample of 14, despite having a policy in place to use the CMS Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Manual as a guide. For Resident #16, the care plan inaccurately documented hospice services even after the resident was discharged from hospice, and there was no corresponding physician order for hospice care. Resident #21's care plan lacked directions for anticoagulant medication and nectar thickened liquids, despite the resident being on Xarelto and requiring a mechanical soft diet. Resident #25's care plan contained conflicting code status information, listing both full code and Do Not Resuscitate (DNR) status, and failed to include directions for toileting, hygiene, dressing, or the use of a right arm tray on the wheelchair, despite the resident's observed needs. Resident #32's care plan did not include a plan for hospice care, even though the resident had a signed contract and consent for hospice services. Resident #33's care plan did not address the use of bed rails, which were observed in use, and there were no corresponding physician orders for bed rail use. Resident #49's care plan was missing directions for code status and bed rail use, despite observations of the resident using bed rails and having a full code status order. Resident #50's care plan did not address the resident's smoking habits, even though the resident was documented as a smoker and confirmed this during an interview. Interviews with facility staff, including CNAs, LPNs, the ADON, and the Administrator, revealed that care plans were not updated as required, and there was a lack of alignment between care plans and physician orders, leading to deficiencies in resident care planning.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility staff failed to provide activities of daily living (ADLs), specifically showers, for eight residents out of fourteen sampled. These residents were not consistently listed on the master shower schedule, leading to missed showers. The facility's policy required residents to be on the shower schedule twice a week, but this was not adhered to, resulting in some residents not receiving showers as needed. Resident #9, who was severely cognitively impaired and dependent on staff for hygiene and bathing, was not on the master shower list. Similarly, Resident #21, who required maximum assistance for transfers, toileting, and dressing, was listed to receive showers twice a week, but there was no documentation to confirm these showers were provided. Resident #23, who was cognitively intact but required assistance for bathing, reported not receiving showers twice a week as scheduled, leading to discomfort. The facility's failure to maintain an updated and accurate master shower schedule contributed to the deficiency. Interviews with staff, including the Certified Medication Technician (CMT), Certified Nurse Assistant (CNA), Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON), and the administrator, revealed a lack of clarity and responsibility in updating the shower schedule. This oversight resulted in residents, including those receiving hospice care, not being offered showers as required, highlighting a systemic issue in the facility's management of resident care.
Failure to Conduct Bed Rail Assessments and Obtain Consent
Penalty
Summary
The facility failed to complete necessary bed rail assessments and obtain informed consent for the use of bed rails for three residents out of a sample of 14, despite having a policy in place that requires these actions. The policy mandates staff to conduct bed rail observations, obtain consent, educate residents or their representatives on the risks and benefits, and develop a care plan for bed rail use. However, for Residents #21, #33, and #49, these steps were not followed, as evidenced by the lack of documented assessments and consents in their medical records. Resident #21 was assessed as requiring maximum assistance for various activities and had physician orders for bed rails, yet the medical record showed only one bed rail assessment and consent, with no further documentation. Observations confirmed the consistent use of bed rails without updated assessments or consents. Similarly, Resident #33, who was cognitively intact and required supervision for some activities, had no documented bed rail assessment or consent, despite observations showing the use of bed rails. Resident #49, with severe cognitive impairment, also lacked documentation for bed rail assessments and consents, although bed rails were observed in use. Interviews with facility staff revealed confusion and inconsistency regarding responsibilities for bed rail assessments and consent. LPN C, the maintenance person, the Nurse Consultant, and the Administrator provided conflicting information about who was responsible for these tasks and how often they should be completed. The maintenance person admitted to not performing entrapment measurements, and there was uncertainty about who should conduct these measurements. This lack of clarity and adherence to policy contributed to the deficiency in ensuring resident safety regarding bed rail use.
Failure to Ensure Timely Completion of Nurse Aide Training
Penalty
Summary
The facility failed to ensure that four nurse aides completed the required nurse aide training program within four months of their employment. The facility's policy did not provide guidelines for the completion of the nurse aide training program, and the Facility Assessment Tool indicated that all nurse aides must be certified within 120 days. Personnel files for the nurse aides in question lacked documentation of completed training, and observations revealed that one of the nurse aides did not perform proper hand hygiene during care procedures. Interviews with various staff members, including the Business Office Manager, Administrator, Director of Nursing, ALF Coordinator, Assistant Director of Nursing, and Nurse Consultant, revealed a lack of clarity and communication regarding the responsibility for monitoring the completion of the CNA training. The ALF Coordinator was identified as responsible for tracking CNA class completion, but there was a breakdown in communication and follow-up, resulting in the nurse aides being out of compliance and continuing to work without completing their training. The facility staff were aware of the issue but did not take effective action to address it, leading to the deficiency.
Failure to Reconcile Narcotics at Shift Change
Penalty
Summary
The facility staff failed to adhere to their policy regarding the reconciliation of narcotics at the change of shift. The policy required that narcotics be counted and verified by two licensed staff members at each shift change, with both individuals signing the narcotic count log to confirm the accuracy of the count. However, a review of the narcotic count sheets from April to July 2024 revealed numerous instances where the sheets lacked the required two signatures, indicating that the counts were not consistently performed by two staff members as mandated. Observations and interviews with staff members further confirmed the deficiency. On one occasion, an LPN was observed beginning their shift without completing a narcotic count with the outgoing nurse. Interviews with various staff, including LPNs, CMTs, the Assistant Director of Nursing, and the Nurse Consultant, revealed a pattern of non-compliance with the narcotic counting procedure. Staff members admitted to either not performing the counts or doing so alone, contrary to the facility's policy. The facility's leadership, including the Administrator and the Director of Nursing, were unaware of the lapses in narcotic counting procedures. They expressed expectations that the counts be completed by two licensed staff members at each shift change and that both sign the narcotic log. The failure to consistently follow the established procedure for narcotic reconciliation at shift changes represents a significant deficiency in the facility's pharmaceutical services.
Deficiency in Hand Hygiene Practices
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene protocols, leading to a deficiency in infection prevention and control. Observations revealed that staff members did not perform hand hygiene after glove removal and before donning new gloves during incontinence care for three residents. For Resident #14, staff members were observed changing gloves without washing hands after providing bowel incontinence care. Similarly, for Resident #24, a CNA applied barrier cream with soiled gloves and changed gloves without hand hygiene. For Resident #35, a CNA changed gloves multiple times during catheter and incontinence care without performing hand hygiene. The facility's handwashing policy did not address the use of alcohol-based hand sanitizers or provide specific guidance on when to wash hands. Interviews with staff indicated a lack of available hand sanitizers in resident rooms, complicating adherence to proper hand hygiene practices. The Director of Nursing acknowledged the expectation for staff to perform hand hygiene during care transitions and noted that pocket-sized hand sanitizers were available, although the Administrator contradicted this by stating they were not available to staff.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed rails as part of their maintenance program, leading to potential safety risks for four residents. The facility's policy required regular inspections of bed frames, mattresses, and bed rails to identify areas of possible entrapment, but this was not adhered to. The FDA guidelines highlight the risks associated with bed rails, including entrapment, strangulation, and other injuries, particularly for vulnerable populations such as the elderly. Resident #21 was assessed as requiring maximum assistance for various activities and had an order for bed rails for positioning. However, there was no entrapment assessment or measurements in the resident's medical record, and observations showed the resident consistently had both half bed rails up. Similarly, Resident #25 had moderate cognitive impairment and required assistance for mobility and other activities. The bed rail assessment for this resident showed measurements that did not pass the entrapment criteria, yet staff documented them as passed. Residents #33 and #49 also had discrepancies in their care plans and medical records regarding bed rail use and entrapment assessments. Observations showed both residents with half bed rails up, but their records lacked necessary entrapment measurements. Interviews with staff revealed confusion and lack of clarity about who was responsible for conducting entrapment measurements, with different staff members providing conflicting information. This lack of coordination and adherence to safety protocols posed a risk of harm to the residents.
Improper Waste Containment
Penalty
Summary
The facility staff failed to properly contain waste and refuse, leading to the potential harboring and feeding of rodents and pests. Observations on two consecutive days revealed that the outdoor dumpster, which contained waste, was uncovered and lacked lids or doors. Additionally, paper and food waste were scattered on the ground around the dumpster, and a plastic bag of waste was found on the ground near the dumpster. On the second day, two cats were observed rummaging through the plastic bag of waste. Interviews with the facility administrator and the Dietary Manager revealed that there was no written policy for waste disposal or maintenance of waste disposal areas, and both were unaware that the dumpster did not have a lid.
Misappropriation of Resident Funds by Facility Staff
Penalty
Summary
Facility staff failed to prevent the misappropriation of funds for a resident when a housekeeper stole the resident's wallet and used the debit card without consent. The facility's policy mandates protection of residents from abuse, neglect, exploitation, and misappropriation of property. Despite this, the housekeeper accessed the resident's room, took the wallet, and used the debit card for unauthorized transactions totaling $308.96. The resident, who was cognitively intact, noticed the wallet missing and reported unfamiliar charges to the bank. The facility conducted an investigation and involved the Department of Health and Senior Services and the local police. The police confirmed the housekeeper's unauthorized use of the debit card through surveillance footage and interviews. The housekeeper admitted to taking the wallet and using the card without permission. The incident highlights a failure in safeguarding the resident's belongings, as the housekeeper had access to the resident's room and exploited this access for personal gain.
Failure to Ensure Operational Call Light System
Penalty
Summary
The facility staff failed to ensure the wireless call light system was fully operational at all times, as direct care staff did not consistently carry and utilize the wireless nurse call pagers. This deficiency had the potential to affect all 56 residents in the facility. The facility's policy on call light answering did not provide clear instructions on the use of pagers, and an approved exemption required staff to carry and use the pagers at all times to ensure resident care was not adversely affected. The call light report from a specific period showed numerous instances where call lights were not answered promptly, with delays ranging from 31 to 166 minutes. Observations revealed that the facility relied on a central call light computer station and scrolling ticker screens at the end of hallways to alert staff, rather than individual pagers. Interviews with staff members, including CNAs and a CMT, indicated that pagers were often not worn due to being lost or taken home, and staff relied on the ticker screens and computer stations to monitor call lights. The Director of Nursing and the administrator acknowledged the issue, noting that staff should wear pagers to be alerted immediately when a call light is activated. They stated that call lights should be answered within 15 minutes, with a maximum acceptable delay of 30 minutes. However, the report documented that call lights were frequently left unanswered for much longer periods, which could potentially result in harm to residents.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility staff failed to revise comprehensive person-centered care plans for four residents who experienced falls. The facility's policy requires ongoing assessment and updating of care plans when significant changes occur in a resident's condition. However, the care plans for these residents did not include new interventions or reviews following their falls, despite the Director of Nursing (DON) acknowledging responsibility for ensuring updates after such incidents. Resident #2, who is cognitively impaired and has a history of falls, was found on the bathroom floor, but the care plan was not updated with new interventions. Similarly, Resident #13, who is cognitively intact with a seizure disorder and traumatic brain dysfunction, experienced two falls, yet the care plan lacked new interventions. Resident #14, also cognitively intact, fell while attempting to get into bed without assistance, but the care plan did not reflect any new interventions. Resident #18, with schizophrenia, fell from bed, but the care plan was not updated despite an increase in antipsychotic medication. The facility's process for communicating care plan updates to staff was inadequate. CNAs do not have access to event reports, and the DON relies on nurses to verbally communicate changes. The MDS nurse is responsible for ensuring care plan updates, but the lack of access to event investigations for floor staff and reliance on verbal communication led to deficiencies in care plan updates after falls.
Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
Facility staff failed to provide timely toileting assistance and incontinence care for a resident, leading to the resident remaining unclean and wet. The resident, who was cognitively impaired and had functional impairment on one side due to hemiplegia, required substantial assistance for toileting and was frequently incontinent of bladder and occasionally incontinent of bowel. The care plan did not specify how often to offer toileting or provide incontinence care. During an observation, a CNA transferred the resident to the toilet and found the resident's clothing and wheelchair pad saturated with urine. The CNA did not perform perineal care, leaving the resident with a smell of urine. Interviews with facility staff, including the CNA, DON, and administrator, revealed that residents should be toileted every two to three hours to prevent skin breakdown and infection. The CNA admitted to being in a hurry and not performing the necessary perineal care, while the DON and administrator emphasized the importance of regular toileting and perineal care. The facility's Perineal Care policy lacked specific instructions on the frequency of care, contributing to the deficiency.
Failure to Secure Safety Straps During Mechanical Lift Transfer
Penalty
Summary
Facility staff failed to provide safe transfers with a mechanical lift for a resident, leading to a deficiency in accident prevention. The facility's Hydraulic Lift policy, which was undated, required adherence to the manufacturer's instructions for safe use. The hydraulic lift manual from September 2023 specified that residents should have some weight-bearing ability, upper body strength, and the ability to follow simple commands. It also required the safety strap to be securely fastened around the resident's torso, with the resident's arms positioned outside the harness and hands on the paddle handles. Additionally, if necessary, shin straps should be used to keep the resident's feet on the footplate. During an observation, a CNA assisted a cognitively impaired resident with hemiplegia in a transfer using the lift but failed to secure the safety strap around the resident's torso. The resident's right arm was not holding onto the lift, and the shin strap was missing. The CNA acknowledged the missing shin strap and the need to secure the chest strap. Interviews with the DON and the administrator revealed that staff had received transfer training, and both were unaware of the missing shin strap. The administrator expected staff to use the lift as intended by the manufacturer to prevent falls or injuries.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
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